Care Transitions and Caring Transitions®
By Nan Hayes
Individuals with chronic health conditions often require a variety of care services provided by multiple practitioners. Typically, each provider of services operates in a unique setting. For instance, as a patient’s needs change, they may transfer from their home setting to a hospital, then from hospital to a rehabilitation center or nursing facility, then perhaps return home where they receive additional care. The patient may also schedule office visits with primary care and specialty care physicians.
Each of these changes in practitioner or healthcare setting is called a “Care Transition.” Traditionally, providers in each of the care settings operate individually, with little or no knowledge of what services or information was given to the patient by any of the other providers. Among providers it is known that poorly managed transitions can diminish health and increase healthcare costs. The lack of coordination among care services may also lead to poor clinical outcomes, dissatisfaction by patients and their families and even readmissions to the hospital.
According to the Centers for Medicaid and Medicare Services (CMS) nearly one in five Medicare patients discharged from a hospital, or 2.6 million seniors, are readmitted within 30 days, at a cost of over $26 billion every year. Clearly this indicates room for improvement in care transitions. In addition to readmission, patients may suffer other complications due to unclear discharge instructions, conflicting instructions from different providers and medication errors, such as dangerous drug interactions or overdose due to duplication of prescriptions.
On the other hand, when care transitions are managed optimally, quality of care is increased and readmission of a patient can be reduced. According to the American Geriatrics Society, good transitional care is based on a comprehensive plan of care, as well as the availability of health care practitioners who are trained in chronic care and have current information about the patient’s goals, preferences, and clinical status.
Good transitional care will also include these 6 principles:
- Planning and logistical arrangements
- Use of technology to promote the exchange of information
- Education for the patients, their families and caregivers
- Support assessments and service referrals
- Patient follow up
- Performance standards, measurements and reporting
At Caring Transitions®, we understand the value of these care transition principles and apply them to other areas of late life transition, such as “home transition.” While clearly different from health transitions, “home transitions” encompass the changes to an individual’s living environment. In later life, home transitions typically include a move from the family residence to an assisted living community, nursing care or a rehabilitation center. Additional changes to home environment may include downsizing, decluttering or modification to an existing residence to improve comfort and safety. And lastly, a home transition may be the transfer of an estate to a trustee, who is then responsible for the management or liquidation of the estate. In all cases, Caring Transitions® provides the necessary transitional planning and services to help assure the best possible outcomes for the client.
Please join our blog and newsletter over upcoming weeks as we explain “What Families Should Know” when it comes to transition services and standards.
©Caring Transitions 2015. No reprint in part or entirety without permission.
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